7.

Technetium mana yang untuk menilai sklerosis ginjal dan menilai GFR pakai apa pada
renogram?

Answer:

TECHNETIUM USED FOR GFR MEASUREMENT IN RENOGRAM

99mTc-Diethylenetriaminepentaacetic Acid (DTPA) (Glomerular Filtration)

99mTc-DTPA is the only renal radiopharmaceutical available for routine imaging that is
purely filtered by the glomerulus; consequently, it is the only imaging radiopharmaceutical
that can be used to measure glomerular filtration rate (GFR). In healthy subjects, the
extraction fraction of 99mTc-DTPA (the percentage of the tracer extracted with each pass
through the kidney) is approximately 20%; this extraction fraction is relatively low compared
with the extraction fraction of tubular tracers (41%–86%)

51Cr-Ethylenediaminetetraacetic Acid (EDTA) (Glomerular Filtration)

51Cr-EDTA is a nonimaging radiopharmaceutical used to measure GFR via plasma sampling

techniques; it is not available in the United States.

125I-Iothalamate (Glomerular Filtration)

125I-iothalamate is used to measure GFR via plasma sampling techniques. 125I does not emit
a photon of sufficient energy to be useful for renal imaging.

99mTc-Glucoheptonate (GH) (Cortical Retention and GFR)

99mTc-GH is cleared primarily by glomerular filtration, but approximately10%– 15% of the

injected dose is retained in the renal tubules, allowing delayed, high-resolution static images
to be obtained. 99mTc-GH tends to be used for static imaging if 99mTc-DMSA is
unavailable; because of the parenchymal retention, it should not be used for diuretic
renography.

Reference:

1. Taylor AT. Radionuclides in nephrourology, part 1: Radiopharmaceuticals, quality control,

and quantitative indices. J Nucl Med. 2014;55(4):608-615. doi:10.2967/jnumed.113.133447

Radiofarmaka GFR  99mTc-DTPA is cleared from the blood exclusively by glomerular filtration
and is therefore the agent most suited to measurement of GFR. 99mTc-DMSA clearance is dependent
on glomerular filtration.

Radiofarmaka glomerulosclerosis/Obstruksi 99mTc-MAG3 is preferred for diuretic renography

because it has highextraction by the kidneys, rapid clearance, low radiation dose, and tubular secretion

References : Campbell-Walsh Urology 11th ed page 1092

8. Bagaimana cara melakukan renogram diuretic?

Answer:

Step in conducting the diuretic renogram:

A. Study request

The study request should ideally specify the questions to be answered, provide a relevant
history, and give instructions on the clamping of nephrostomy tubes if they are present. If the
request is vague or incomplete, the referring physician needs to be contacted to provide
clarification. The interpreting physician should review all available pertinent clinical,
laboratory, and radiologic data before performing the study. This information may include the
presence of clinical signs of obstruction, such as flank pain, reduced urine volume, and
increased urgency and frequency of urination; the most recent serum creatinine level; whether
the patient is pregnant or breastfeeding; current diuretic medications and dosages; fluid
restrictions; medication allergies; the results of prior imaging procedures evaluating the
kidneys and ureters; and relevant urologic procedures or surgeries (nephrostomy tubes and
whether clamping should occur, ureteral stents, bladder catheters, urinary diversion, renal
transplant, and location).

B. Patient information

Information describing the study and needed hydration should be provided to outpatients
before arrival.

C. Hydration

Unless there is a contraindication, the patient should be instructed to arrive well hydrated and
should receive an additional oral fluid load of 5–10 mL/kg of body weight 30–60 minutes
before the procedure.8 If intravenous hydration is clinically indicated, it can be accomplished
with a volume of fluid comparable with the amount of water recommended for oral
hydration. Intravenous fluid consisting of dextrose in water is recommended as the goal is not
volume replacement but maximization of urine output.

D. Diet

No special diet is required. Fasting before the study should be avoided as it may result in a
relatively dehydrated patient.

E. Chronic diuretic administration

If receiving chronic diuretics, the patient should hold them the morning of the study to
support adequate hydration.

F. Pregnancy
If the patient is pregnant or thinks she may be pregnant, the nuclear medicine physician
should counsel her regarding the necessity of the study and radiation risk before she arrives
for the test.

G. Breastfeeding

Interruption of breastfeeding is not required. Using 1 mSv as the estimated threshold dose to
the infant, Stabin and Breitz recommend no cessation of breastfeeding for 99mTc-
diethylenetriaminepentaacetic acid (DTPA), 99mTc-mercaptoacetyltriglycine (MAG3), or
123I-orthoiodohippurate.9 The EANM Task Group Explaining Risks agreed that interruption
of breastfeeding was not essential but that the mother could be reassured by a 4-hour
interruption for 99mTc-MAG3 and a 12-hour interruption for 99mTc-DTPA and 123I-
orthoiodohippurate.10 Publication 106 of the International Commission on Radiological
Protection likewise recommends no cessation of breastfeeding, although discarding one meal
of expressed milk after imaging could be considered a conservative alternative.11 With the
availability of suitable alternatives, 131I-orthoiodohippurate should not be administered to
women who are pregnant or breastfeeding.

H. Injection technique

It is essential to avoid infiltration of the tracer or furosemide. Infiltration can be minimized by

injecting through an established cannula rather than by direct injection into a vein.

I. Safety of furosemide

Furosemide is a nonantibiotic sulfonamide, leading to questions about its safety in patients

reporting a reaction to sulfonamide antibiotics. Although there is an association between
hypersensitivity after receipt of sulfonamide antibiotics and a subsequent allergic reaction
after receipt of a sulfonamide nonantibiotic, this association appears to be due to a general
predisposition to allergic reactions rather than to any specific cross-reactivity with
sulfonamide-based drugs.12 The immunologic determinant of IgE-mediated immunologic
responses to sulfonamide antibiotics is the N1 heterocyclic ring; this N1 heterocyclic
structure is not present in nonantibiotic sulfonamides such as furosemide13; consequently, in
the absence of the N1 heterocyclic ring, cross-reactivity is not expected. The lack of cross-
reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics is supported by
recent reviews.12–15

To put the risk of an allergic reaction from furosemide into clearer context, the risk of an
allergic reaction after receipt of a sulfonamide nonantibiotic was higher among patients with
a history of hypersensitivity to penicillins than among patients with a history of
hypersensitivity to sulfonamide antibiotics.12 In fact, most prescribers do not view the use of
sulfonamide nonantibiotics as problematic in the sulfonamide-allergic patient.15 In keeping
with this point of view, most members of the standards/guideline committee do not check for
a history of allergic reactions to sulfonamide antibiotics, and furosemide is administered as a
bolus over a few seconds; based on a combined experience of several thousand patients using
this approach, no allergic responses to furosemide have been observed by the members of the
writing committee.

J. Bladder catheterization

A bladder catheter should be inserted after consultation with the referring physician if the
patient is anticipated to have difficulty voiding. If a bladder catheter is required or already in
place, it should be allowed to drain freely, as free drainage facilitates assessment of upper
tract drainage. If there has been recent bladder surgery, free drainage is essential to avoid the
risk of leakage through the surgical incision.

PILIHAN RADIOFARMAKA

A. 99mTc-MAG3 (tubular secretion)

Because of its more efficient extraction, 99mTc-MAG3 is preferred over 99mTc-DTPA in

patients with suspected obstruction and impaired renal function.5,6,21–24

B. 99mTc-L,L- and -D,D-ethylenedicysteine (tubular secretion)

99mTc-L,L and -D,D-ethylenedicysteine are enantiomers. Both are excellent renal

radiopharmaceuticals, with clearances slightly higher than that of 99mTc-MAG3.

C. 123I- and 131I-orthoiodohippurate (tubular secretion)

123I- and 131I-orthoiodohippurate are cleared primarily via organic anion transporter 1 in the
proximal tubules, although a small component is filtered by the glomeruli. The clearance of
orthoiodohippurate is approximately 500–600 mL/min in subjects with normal kidneys. The
poor imaging characteristics of 131I, the potential of 131I-orthoiodohippurate for delivering a
high radiation dose, and the unfavorable logistics resulting from the relatively short half-life
of 123I have caused these radiopharmaceuticals to fall out of favor.29,30

D. 99mTc-DTPA (glomerular filtration)

99mTc-DTPA is the only radiopharmaceutical available for renal imaging that is filtered
purely by the glomerulus; consequently, it is the only radiopharmaceutical that can be used
both to image the kidney and to measure glomerular filtration rate. In healthy subjects, the
extraction fraction of 99mTc-DTPA (the percentage of the tracer extracted with each pass
through the kidney) is approximately 20%; this extraction fraction is relatively low compared
with the extraction fraction of tubular tracers (41%–86%).19,20,31

Dose of furosemide

The standard adult dose of furosemide is 0.5 mg/kg or 40 mg.21,51 In adults with normal
renal function, 40 mg of furosemide produces maximal diuresis, with urine flow rates
reaching approximately 20 mL/min within 3–6 minutes.41,44,52,53 In fact, a 20- to 30-mg
dose of furosemide usually produces adequate diuresis in a young adult with normal renal
function. Patients with impaired renal function, however, may not have an adequate diuretic
response to 40 mg of furosemide and the dose may need to be increased to achieve an
adequate diuretic response.

Bumetanide

If furosemide is not available, bumetanide is an acceptable alternative. One milligram of

bumetanide is equivalent to approximately 40 mg of furosemide.

Urine flow rate

The rate of urine flow can be calculated by dividing the voided volume at the conclusion of
the study by the interval between the time of prestudy voiding and the time of poststudy
voiding.

INTERPRETATION

A. Whole-kidney ROIs and renogram curves

Time-activity curves can be generated after placement of ROIs. The whole-kidney ROI is
placed around the entire kidney, including the renal pelvis, and is required to measure relative
tracer uptake in each kidney. The renogram curve generated from the whole-kidney ROI will
be affected by retention of tracer in both the parenchyma and the pelvis. Tracer retention may
occur in pathologic states such as diabetic nephropathy or obstruction but may also occur in
nonpathologic states such as a non–obstructed dilated collecting system or mild dehydration.

B. Cortical (parenchymal) ROIs and renogram curves

To better assess parenchymal function, ROIs can be restricted to the renal cortex, excluding
any retained activity in the renal pelvis or calyces. The function of the cortical curve is to
evaluate parenchymal function by displaying the transit time through the cortex without
contamination by activity in the collecting system. Parenchymal ROIs are drawn specifically
to exclude activity in the pelvis and calyces, not to have equal areas.56 Consequently, it is the
shape of the cortical renogram that is important, not the absolute height. A difference in
relative height between cortical curves does not indicate relative cortical function but is due
simply to a difference in size between the relative cortical ROIs; a larger cortical ROI will
have more counts than a smaller one.

C. Pelvic ROIs

For the diuretic portion of F + 20 and dual-acquisition studies, renogram curves and
quantitative measurements can be derived from restricting placement of the ROI to activity in
the renal pelvis and collecting system rather than placing the ROI over the whole kidney.
Pelvic ROIs that only include retained activity in the collecting system and that avoid the
parenchyma allow better assessment of the response to furosemide than do whole-kidney
ROIs.

D. Background correction
Background consists of radiotracer present in blood, the interstitial space of the kidney, and
tissues anterior and posterior to the kidney. For tracers with a low extraction fraction, such as
99mTc-DTPA, the background counts during the second to third minutes after injection can
be as high as 50%–80% of the total activity in the renal ROI, particularly in patients with
reduced renal function.8 To correct for these nonrenal counts in the renal ROI, background
correction needs to be performed. In calculations of relative renal uptake, a perirenal
background ROI slightly separated from the whole-kidney ROI to avoid scatter from the
latter is preferred over a background ROI superior, medial, or inferior to the whole-kidney
ROI. Counts in the background ROI must be normalized to the kidney ROI. Automated
background assignments that track the kidney ROI reduce processing time and enhance
reproducibility. If the background ROI includes tracer that subsequently accumulates in the
renal pelvis, background may be oversubtracted in the latter part of the study, leading to
errors in generating quantitative drainage parameters. Further details on background
correction methods and quality control of quantitative measurements of renal function are
available in a consensus report from the International Scientific Committee of Radionuclide
in Nephrourology.

E. Relative function

The relative uptake measurement is often dependent on the software available and is usually
made by placing an ROI over each kidney and measuring the integral of the counts in the
renal ROI for 1–2, 1–2.5, or 2–3 minutes after injection or using the Rutland-Patlak plot.8
For the integral method or when patients receive furosemide at the beginning of the study (F
= 0), the 1–2 or 1–2.5-minute time periods are preferred8; specifically, the measurement
should be made before any activity has drained into the ureter or bladder. If the measurement
is made after significant activity appears in the ureter or bladder, the relative uptake
measurement may be spurious because the rate of initial urine drainage from the two kidneys
may not be proportional. A simple visual quality control check can be performed to ensure
the measurement interval occurs before the earlier peak of the two renogram curves.

F. Renal size

Routine measurement of renal size at the time of the 99mTc-MAG3 scan may assist in the
detection of unsuspected bilateral increases or decreases in renal size and facilitate scan
interpretation as several chronic renal diseases will result in bilaterally small kidneys.
Conversely, the kidneys may be bilaterally enlarged in early diabetic renal disease, acute
interstitial nephritis, HIV nephropathy, and amyloidosis. Renal size (length in cm and area in
cm2) can be determined from the pixel size and whole-kidney ROI from the 99mTc-MAG3
renal scan. The mean left and right kidney length (±SD) is 12.2 ± 1.0 cm and 12.1 ± 1.0 cm,
respectively, in men and 11.9 ± 0.9 and 11.8 ± 0.9, respectively, in women; the upper and
lower limits of renal length and area normalized to body surface area have been previously
published.

G. Time to peak
The time to peak refers to the time from radiopharmaceutical injection to the peak height of
the renogram. In hydrated subjects, 99mTc-MAG3 and 99mTc-DTPA renograms typically
peak by 5 minutes after injection and decline to half-peak by 15 minutes. However,
physiological retention of the tracer in the renal calyces or pelvis can alter the shape of the
whole-kidney renogram in normal kidneys and lead to a prolonged time to peak, 20 minute to
maximum count ratio, and half-time (T1/2) measurement.

H. T½ calculation

The T1/2 refers to the time it takes for the activity in the kidney to decrease to 50% of its
maximum value. The methodology for calculating T1/2 is not standardized and tends to be
vendor- or institution-specific. T1/2 measurements are affected by the choice of
radiopharmaceutical, the interval between administering it and administering furosemide, the
method of hydration, the bladder volume, the presence or absence of a bladder catheter, the
dose of furosemide, the selection of ROI, the measurement interval, and the algorithm used to
fit the washout curve for calculating T1/2.

I. Postvoid kidney to maximum (postvoid/max) count ratio

Simple ratios that incorporate gravity-facilitated drainage from the kidneys, such as counts in
the postvoid kidney divided by the maximum counts in the kidney normalized for time,
appear to provide more robust measurements of drainage than the T1/2.3,43,57 In a study
using a dual-acquisition protocol, the mean baseline postvoid/max count ratio for kidneys
interpreted as having normal drainage was 0.18 ± 0.16.57 In the same dual-acquisition study,
the ratio of counts at 20 minutes after furosemide to the maximum counts at baseline was
0.11 ± 0.12 for nonobstructed kidneys.

J. 20 minute to maximum (20 min/max) count ratio

The 20 min/max count ratio is the ratio of the kidney counts at 20 minutes to the maximum
(peak) counts normalized for time; this measurement provides an index of transit time and
parenchymal function and is often obtained for both whole-kidney and cortical ROIs. For
99mTc-MAG3, the normal 20 min/max count ratio for cortical ROIs averages 0.19, with SDs
of 0.07 and 0.04 for the right and left kidneys, respectively.62 If the patient is not dehydrated
and the 20 min/max count ratio for the cortical ROI exceeds 0.35 (>2–3 SDs above the
mean), kidney function is likely to be abnormal. In addition to detecting abnormal function,
the 20 min/max count ratio and the 20-min/1–2 min count ratio can be useful in monitoring
patients with suspected urinary tract obstruction and renovascular hypertension.

K. Clearance measurements

A measure of renal function can assist in the performance and interpretation of the study,
especially as a reduction in renal function may result in delayed tracer uptake and washout
even in the absence of obstruction. A reduction in renal function may indicate the need to
administer a higher dose of furosemide to achieve an adequate diuretic response. When
available, the serum creatinine level provides a global estimate of renal function. A clearance
measurement can also be made at the time of the study using plasma- or camera-based
clearance measurements. Plasma-based clearances are more accurate than camera-based
clearances, but camera-based clearances avoid blood sampling and provide an estimate of
global and individual renal function. Plasma- and camera-based clearance measurements
have been discussed in more detail in review articles.

L. Parenchymal transit time

Obstruction of the renal outflow tract has a deleterious effect on nephron function
(obstructive nephropathy) that can be detected by a prolonged parenchymal transit time. A
prolonged parenchymal transit time is not specific to obstruction but increases the likelihood
of its presence. The parenchymal transit time calculation is not offered on many commercial
systems but can be implemented by following the recommendations in a previously published
consensus report.

M. Image display

Static images should be displayed in 1-to 2-minute intervals. The postvoid images should be
displayed using the same formatting as the dynamic images to facilitate visual comparison.
Images should also be viewed in a cinematic display for optimal interpretation.

Reference:

1. Taylor AT, Brandon DC, de Palma D, et al. SNMMI Procedure Standard/EANM Practice
Guideline for Diuretic Renal Scintigraphy in Adults With Suspected Upper Urinary Tract
Obstruction 1.0. Semin Nucl Med. 2018;48(4):377-390.
doi:10.1053/j.semnuclmed.2018.02.010

9. Bagaimana cara membedakan torsio testis dan orchitis?

Answer:

Comparison Torsio Testis Orchitis

Definition Emergency case in urology. It is
an acute vascular event causing
the rotation of the vascular
pedicle of the testis, thereby
impeding the blood flow to the
testis and the scrotal contents.
Etiology congenital anatomical
abnormalities, hypermobile
testis, loose and abnormal
connections between testis and
adnexae, polyorchidopathia,
some of the abnormalities of
tunica vaginalis like capacious
tunica vaginalis and high
Non-emergency case in urology. It
is an infection and inflammation of
the testis
Bacterial or viral infection;
Blood-borne dissemination is the
major route of isolated testicular
infection. Mumps is the most
common cause of viral orchitis
(orchitis occurs in 20 to 30
percent of men with mumps
infection)
 investment of the tunica have
been thought to contribute to
testicular.1
Typical presentation2 Acute onset of pain, usually severe Abrupt onset of testicular pain and
swelling.
Patient may accompanied by another
symptoms such as fever, nausea,
vomit, or headache.
Examination findings High-riding transversely oriented Testicular swelling and tenderness;
testis; abnormal cremasteric reflex; normal cremasteric reflex; phren’s
pain with testicular elevation; “bell sign (+); cremaster reflex (+)
clapper deformity”; phren’s sign
(-);cremaster reflex (-)
Ultrasound findings Normal-appearing testis with Testicular masses or swollen
decreased blood flow on color testicles with hypoechoic and
Doppler USG.3 hypervascular areas
References:
1. Pentyala S, Lee J, Yalamanchili P, Vitkun S, Khan SA. Testicular torsion: A review. J Low
Genit Tract Dis. 2001;5(1):38–47.

2. Khanna K, Liu DR. Epididymitis and orchitis. Fleisher Ludwig’s 5-Minute Pediatr Emerg Med
Consult. 2012;79(7):583–7.

3. Jawa Z, Okoye O. Differentiating acute epididymitis from testicular torsion using scrotal
scintigraphy. Sahel Med J. 2017;20(3):89.

Orchitis is typified by testicular pain that may be relieved by maneuvers that elevate or
support the testis. Torsion of the testicle or its appendages result in acute vascular congestion
and pain (and in the case of testicular torsion is a surgical emergency).

Orchitis is non-emergency pediatric case of acute scrotal pain and is managed

nonoperatively. Color-flow Doppler sonography demonstrates increased testicular flow
(Tarantino et al., 2001).

For evaluating in order to distinguish the testicular torsion and orchitis, urine culture should
be obtained because it has been reported to be positive in 38.5% of patients diagnosed with
isolated orchitis. Imaging with scrotal US can help to distinguish testicular torsion from
orchitis and identify testicular tumors and abscess.

Based on the testicular scintigraphy as it typically promoted to distinguish between testicular

torsion and inflammatory conditions of the testicle (i.e., epididymitis, orchitis, testicular
appendage torsion) (Holder et al., 1981). The test is performed by intravenous injection of
99m
Tcpertechnetate followed by dynamic and static gamma images of the pelvis. Similar to
renal scintigraphy, photon-deficient areas represent poor blood flow as in torsion, and
photon-hyperdense areas can represent inflammation as in orchitis.

In patients with signs of infectious orchitis, antibiotics to treat gram-negative uropathogens

should be started and treatment adjusted based on the result of urine culture. Mumps orchitis
can be treated by interferon but does not always prevent testicular atrophy (Ku et al., 1999).
Secondary autoimmune orchitis may be treated with systemic medications, including
corticosteroids, immunosuppressive medications such as azathioprine, or IV
cyclophosphamide, and intravenous immunoglobulin.

References:
Campbell Urology-Walsh Urology 11th ed.

10. Bagaimana cara mendeteksi varikokel grade 0 dan bagaimana tampilannya dari color
doppler?

Answer:

Impalpable or subclinical type or grade 0 when it is not palpable or visible at rest or during
Valsalva maneuver, but it is demonstrable by scrotal ultrasound and color Doppler
examination.4

The term of varicocele grade 0 was defined when the diameter of pampiniform plexus on the
Valsava and non-Valsava maneuver was less than 2 mm. It’s been determined that there was
no dilatation of pampinoform plexus. This definition was supported by Pilatz et al6 who
reported that varicocele was the dilatation of pampiniform plexus about 2.45 mm in the relax
position (sensitivity 84%; specificity 81%) and about 2.95 mm on the maneuver (sensitivity
84%; specificity 84%) using doppler ultrasonography.5

References:

4. Hamada A, Esteves SC, Agarwal A. Varicocele Classification. 2016;37–43.

5. Pilatz A, Altinkilic B, Köhler E, Marconi M, Weidner W. Color Doppler ultrasound imaging

in varicoceles: Is the venous diameter sufficient for predicting clinical and subclinical
varicocele? World J Urol. 2011;29(5):645–50.

11. Mengapa radical orchidectomy harus diligasi tinggi?

Answer:

The potential argument against the low cord approach is that with a shorter resection margin
from the cancer, there is a possibility of a positive margin in the proximal spermatic cord
stump and hence leaving micrometastases in the inguinal canal spermatic cord remnant.

Reference:

1. Ashdown DA, Bodiwala D, Liu S. Is high cord radical orchidectomy always necessary for
testicular cancer?. Ann R Coll Surg Engl. 2004;86(4):289-291. doi:10.1308/147870804272
Radical inguinal orchiectomy with high ligation of the spermatic cord at the level of the
internal ring is the procedure of choice for suspected testicular cancer. The spermatic cord
should be ligated at the level of the internal inguinal ring for adequate oncological control
and to facilitate easy identification if further surgery with retroperitoneal lymph node
dissection (RPLND) is required.6

However, a trans-scrotal orchiectomy or biopsy is contraindicated because it leaves the

inguinal portion of the spermatic cord intact and may alter the lymphatic drainage of the
testis, increasing the risk of local recurrence and pelvic or inguinal lymph node
metastasis.7

References :
6. Koschel SG, Wong LM. Radical inguinal orchidectomy: The gold standard for initial
management of testicular cancer. Transl Androl Urol. 2020;9(6):3094–102.

7. Campbell-Walsh Urology 11th ed page 791